RN Utilization Review Case Manager
About The Position
The Utilization Review Specialist RN assumes responsibility and accountability for admission and concurrent reviews to ensure the prevention of denials from all payers, as well as coordination and management of appeals for accounts deemed appropriate for appeal. This role supports compliance with payer, regulatory, and accreditation standards while promoting efficient utilization of healthcare resources and quality patient outcomes. The Specialist works collaboratively with interdisciplinary teams to identify denial trends, improve workflows, and ensure timely resolution of utilization review and appeals processes.
Requirements
- Graduate of an Accredited School of Professional Nursing
- Current Illinois Nursing License
- Current Basic Life Support (AHA or American Red Cross BLS) certification
- Minimum of five years of clinical nursing experience in an acute care setting
Nice To Haves
- Knowledge of InterQual and/or Milliman criteria
- Experience in case management, discharge planning, utilization review, or appeals management
Responsibilities
- Perform admission and concurrent reviews to prevent payer denials.
- Coordinate and manage appeals for accounts.
- Support compliance with payer, regulatory, and accreditation standards.
- Promote efficient utilization of healthcare resources.
- Ensure quality patient outcomes.
- Collaborate with interdisciplinary teams to identify denial trends.
- Improve workflows related to utilization review and appeals.
- Ensure timely resolution of utilization review and appeals processes.
Benefits
- Competitive salary and performance-based incentives
- Comprehensive health, dental, and vision insurance plans
- Retirement savings plan with employer matching
- Vacation time
- Holiday pay
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
